]]>FRED DE SAM LAZARO: In Malawi, one out of every four children dies before reaching the age of five. Famine is chronic, and AIDS has left tens of thousands of orphans, often in the care of struggling grandparents, like Robin Nangwandu. Many children, like his grandson Mcanthony, are HIV positive.

ROBIN NANAGWANDU (through translator): I will continue working until I die. I don’t have enough food stocks, just enough money to buy day to day. It’s not easy to care for a kid who is HIV positive; not easy to shuttle him back and forth to hospital.

DE SAM LAZARO: Until recently, there were just two pediatricians to care for the entire public health system. Dr. Peter Kazembe was one.

(to Dr. Kazembe): How many children in this country, approximately, are HIV positive?

Dr. PETER KAZEMBE: Well, it’s estimated at 83,000 children now.

DE SAM LAZARO: Eighty-three thousand children, and to serve all of them you have two pediatricians?

Dr. KAZEMBE: Two pediatricians, yes.

Getting a checkup

DE SAM LAZARO: Malawi has just one medical school, and Kazembe says most of its graduates leave for more prosperous countries, like neighboring Botswana, Britain, or the United States.

Dr. KAZEMBE: The issues are the same in all the countries in southern Africa, certainly. You know, salaries — poor salaries, poor working conditions. There’s nothing more frustrating than knowing what you need to do but not having the resources to do it.

DE SAM LAZARO: Dr. Kazembe is in charge of one effort to bring health care resources to Malawi. Its center is a modern, American-style clinic, complete with 11 American doctors. They are typically in their first job after residency and will spend at least one year rotating through this busy clinic and also in some Malawian public health facilities. The Pediatric AIDS Corps program is the brainchild of a physician at Baylor College of Medicine in Houston.

Dr. Peter Kazembe

Dr. MARK KLINE (Baylor College of Medicine): You know, obviously a number of long-term solutions have to be put in place to encourage African doctors to remain in Africa and to bring back African doctors who have immigrated to the developed world. But while those fixes are being put in place, we can’t afford to lose a generation of children to this epidemic.

DE SAM LAZARO: With a grant from the drug giant Bristol Myers Squibb, Kline designed a program that pays the doctors a stipend of $40,000 a year. It’s a fraction of what they could earn at home, but the program also pays down up to $40,000 in student loan debt for each year of service.

Dr. KLINE: Half of the doctors that we have in the program could not have participated were it not for the student loan debt repayment provision, because they simply couldn’t afford to do so.

DE SAM LAZARO: Three years after it began, about 60 physicians have been placed in 11 African countries. Their mission is to treat patients, but more importantly to train local providers on the front lines, like nurses and clinical officers. In addition to training, Baylor’s own clinic offers model conditions not found in Malawi’s crowded public health care system, such as working equipment, hygienic facilities, and drugs. That was enough to bring Dr. Portia Kamthunzi home from the U.K, despite a big pay cut.

Dr. Omalara Thomas

Dr. PORTIA KAMTHUNZI: It’s not just the money for me, it is the job satisfaction as well. Working with HIV positive children I feel like I can relate to them better than other people that are coming from other countries, because in a way I know the culture. I know the type of background they are coming from.

DE SAM LAZARO: It may be a modern clinic for Malawi, and it does offer the once prohibitive anti-retroviral or ARV drugs for AIDS. But for the visitors this is a culture of severe limits compared to the “do-whatever-it-takes” American system they trained in.

Dr. CHRIS BUCK: I have one patient I can think of in particular that’s a 17-year-old boy. He’s pretty severely immune suppressed. He’s been on ARVs for a long time, and he has a gastric tumor, and it’s just kind of slowly killing him, unfortunately, and I can think of so many things that I could do for him in the States to improve his prognosis, from diagnostic tests to different medicines, and here I’m really hampered and limited. I really find that to be distressing.

Dr. OMALARA THOMAS: I think every day you wonder and you say to yourself when you’re prescribing these medicines, but what difference really is this going to make? You know, really what they need is food.

Dr. SAEED AHMED: I worked at a very high-acuity-care hospital in New York at Columbia, and if one patient died or two patients died in a week or a month, it would be a big deal. Then we come here and during our time on the wards we might have three or four patients die a day. And coming to terms with that and coming to terms with there being limits to what we can do for kids was shocking and hard.

Dr. Fitzhugh Mullan

DE SAM LAZARO: One prominent advocate says programs like Baylor’s are a payback to poor countries who have long helped fill the doctor and nurse shortages in rich nations.

Dr. FITZHUGH MULLAN (Project Hope): The Baylor AIDS Corps is a spectacular example of nongovernmental commitment to a contribution to certain poor countries in a specific area — pediatric AIDS — that really is part and ought to be part of a larger contribution that we as a country make back to countries that have been generous to us in spite of the economic inequalities between us.

DE SAM LAZARO: Dr. Mullan has long advocated a much larger federal program like Baylor’s. It’s right, not just morally he says, but strategically.

Dr. MULLAN: There are battles for hearts and minds going on in Africa. China is very present. And sending doctors abroad, sending nurses abroad, is partly a statement of what we are beyond Coca-Cola and other commercial enterprises.

DE SAM LAZARO: There’s no shortage of doctors who want to go. For every one chosen, Baylor has to turn away two.

Dr. KLINE: I think most of them do it because they feel that AIDS in Africa is the challenge of this generation. This is a very highly idealistic group of young physicians, by and large, and they want to do something very meaningful. Straight out of their training they want to have an immediate impact.

Dr. Amy Sims

DE SAM LAZARO: The doctors say their Africa stint has been profoundly formative, and likely not their last. New Yorker Omalara Thomas is bringing it full circle in her family. Her parents are Nigerian immigrants to America.

Dr. THOMAS: I’ve been involved with trying to develop, hopefully, a program with Nigerian, I guess you can say, expatriates to the U.S. and physicians there who at some point do want to come back to Nigeria and do want to work.

Dr. AMY SIMS: I’m actually going back for specialist training in a couple months in the States, and specialists are something that are kind of few and far between here in Africa, and so I plan to use that to train African health workers and kind of pass on that knowledge, and so I always see myself coming back to Africa.

DE SAM LAZARO: Amid all the poverty and suffering, they say, are great rewards, like sharing good news with young Mcanthony’s grandfather.

DE SAM LAZARO: Or watching the teen club on the clinic grounds, knowing that without this clinic few of these young patients would still be alive.

For RELIGION & ETHICS NEWSWEEKLY, this is Fred De Sam Lazaro in Lilongwe, Malawi.

/wnet/religionandethics/files/2008/09/re_thumb_cover_gettingacheckup.jpgIn Malawi, one out of every four children dies before reaching the age of five. Famine is chronic, and AIDS has left tens of thousands of orphans, often in the care of struggling grandparents.

BOB ABERNETHY, anchor: Between tragedies such as the one in Myanmar and the disastrous worldwide rise in food prices, a question long debated by relief experts has become urgent: What’s the best way for the U.S. to help the hungry? Under the billion-dollar-a-year Food for Peace program, the government sends others surplus commodities, such as wheat and corn. Would it be more economical and effective to send cash instead? Fred de Sam Lazaro reports from Malawi in southern Africa.

FRED DE SAM LAZARO: At about 10:30 each morning, some 800 children in the southern Malawi village of Kasungu break from their studies for porridge. The principal says attendance climbed 50 percent since the meal program began three years ago. In this country of 13 million, beset by chronic hunger, it’s the only reliable meal of the day for most kids.

BRIGHTON MTIKOMOLA (Principal): They haven’t eaten anything else, so when they come here, take this sort of food — now and then they take this sort of food — then it makes them increase their performance.

DE SAM LAZARO: They have more energy?

Mr. MTIKOMOLA: Yeah, more energy.

DE SAM LAZARO: The soy or maize for the feeding program is mostly donated by many countries, but the largest contributor is the United States, through a program called Food for Peace. It began in the 1950s as a means to use U.S. grain surpluses to help countries hit by food crises. But today Food for Peace has grown into a $1.2 billion program, and it has critics who say U.S. food aid may actually stifle African farmers and perpetuate dependence in recipient countries, and they say Food for Peace benefits American private contractors more than the hungry.

The United States is the world’s single largest food aid donor, but there are intermediaries: agribusinesses and shipping companies, which by law have to be American, and they consume a good part of the U.S. food aid dollar. The Government Accountability Office says two-thirds of that U.S. food aid dollar goes toward administrative overhead.

Last year one of the largest private food aid charities, Atlanta-based CARE, decided it would stop accepting U.S. food donations in 2009.

CECILY BRYANT (Country Director, CARE, Malawi): We felt very strongly that the inefficiency and the waste that was happening throughout the current system just had to be addressed, and if we didn’t take a stand and try and make a change then this would just continue.

DE SAM LAZARO: Bryant argues it would be much more efficient if U.S. assistance came directly in the form of cash. The money could be used to train farmers and to buy grain locally, cutting cost and delivery times while developing markets for African farmers. In fact, several aid agencies generate cash to run just such programs by selling donated American commodities to African wholesalers and traders. The practice is called monetization.

UNIDENTIFIED CARE EXTENSION AGENT (speaking to group of farmers through translator): This is where we grow soy beans. You need 75 centimeters between ridges for highest yields.

DE SAM LAZARO: On this day, care extension agents used test plots to demonstrate new crop varieties and types like soy beans — a high protein crop that is growing in acceptance here in Malawi.

Ms. BRYANT: Food alone isn’t going to change anything in the long run. We’re working with farmers to teach them to harvest greater yields, to be able to market surplus once they reach that level.

DE SAM LAZARO: Despite Malawi’s problems with poor roads and storage and uneven food distribution that leave many hungry, there have been overall grain surpluses. Rains have been good for two years, and subsidies have helped farmers buy seeds and fertilizers. President Bingu Mutharika says Malawi must lessen its dependence on charity.

President BINGU WA MUTHARIKA: We now have had the success — two successive years of surplus. When I took over, we were told Malawi was poor and that we must go to the rest of the world and beg that we are poor, and the world will feel sorry for us. I said no, that’s not the way the world in globalization works. People will come to Malawi to invest in opportunities if we are helping ourselves and they want to be part of that success story. Nobody, nobody wants to be part of a failing story.

DE SAM LAZARO: Indeed, the United Nations food aid agency, the World Food Program, is now using cash it gets from non-U.S. donors to increase local purchases of grain. But for many farmers the concept of a surplus is new — one they almost fear jinxing.

MARY ELLEN MCGROARTY (World Food Program, meeting with farmers): So they don’t anticipate having a surplus this year?

DE SAM LAZARO: These growers weren’t sure how to answer a simple question from an agency better known for giving away rather than buying food.

Ms. MCGROARTY (meeting with farmers): Let them understand that we’re not seeing where we can deliver food to. We’re looking to buy food.

DE SAM LAZARO: Despite such local difficulties, the World Food Program bought 90,000 tons of grain from Malawi last year.

DOMENICO SCALPELLI (World Food Program): That’s a huge amount of food, and it’s the biggest amount — the largest amount we’ve bought ever from Malawi. A lot of it was not only for Malawi, but a lot of it also went to Zimbabwe, it went to Democratic Republic of Congo. We bought food even for West Africa, so — and that was because the price was the best at the time and the quality was good, competed internationally. Part of the philosophy behind it is to try and bring up local farmers and traders to a point where they can, in fact, compete internationally.

DE SAM LAZARO: It’s a goal some in Washington support. The Bush administration has proposed that a quarter of U.S. food grain be sent in cash, and that idea has the support of many Democrats in Congress. But it gets nowhere in the influential House and Senate agriculture committees, whose members come predominantly from farm states. They’ve insisted that all assistance remain in the form of U.S.-grown commodities and shipped on U.S. flag carriers.

Representative Earl Pomeroy, a North Dakota Democrat, says cutting agencies a check instead of sending grain or cooking oils could do more damage in some developing countries.

Representative EARL POMEROY (D-ND): You go into some of these small economies with a check, buy a bunch of commodities for food aid, you’ve just drove prices out of sight. You hurt everybody else.

DE SAM LAZARO: More importantly, Pomeroy says he fears any changes could jeopardize fragile congressional support for what remains the world’s largest food aid program, even though it accounts for just $1.2 billion of the $280 billion U.S. farm program.

Rep. POMEROY: One of the things about the structure of our program is that it’s been able to sustain congressional support through all kinds of political circumstances. Even in the years I’ve been in Congress, I’ve seen very different environments relative to the receptivity of members of Congress to supporting foreign aid.

Ms. MCGROARTY: So for purchasing we want to be targeting associations. I mean, it’s impossible for us to deal individually with each farmer and each farm.

DE SAM LAZARO: World Food Program officials say they make local purchases carefully. They reject criticism that this causes prices to rise. But they’re not about to reject Food for Peace donations.

Mr. SCALPELLI: I am asked this question quite a bit, and I’m not going to bite the hand that helps feed essentially a million Malawians today, and the United States government is indeed the number one largest donor to Malawi still.

DE SAM LAZARO: Other food aid agencies, unlike CARE, say they must continue to monetize their U.S. donations.

(to Nick Ford): Would you not prefer just straight cash assistance?

NICK FORD (Catholic Relief Services): Absolutely, and that’s going to be a much more efficient use of the American taxpayers’ money. We still have a service to provide the target communities for our development activities. Monetization provides resources that do address the root causes of hunger and poverty in these countries.

DE SAM LAZARO: What all sides agree on is that more food aid, whether in cash or food, is needed. Only 30 percent of Malawi’s children receive even this spartan daily school meal, and that number could fall as global food prices continue their record rise.

For Religion & Ethics NewsWeekly, this is Fred de Sam Lazaro in Lilongwe, Malawi.

Between tragedies such as the one in Myanmar and the disastrous worldwide rise in food prices, a question long debated by relief experts has become urgent: What’s the best way for the U.S. to help the hungry?/wnet/religionandethics/files/2008/05/thumb01-foodaidethics.jpg